Trump Administration Finalizes Pared Back MA And Part D Rule for 2026
The 2026 Medicare Advantage (MA) and Part D rule was finalized by the new Trump administration and it did not finalize many portions of the Biden administration proposed rule. These could be acted on after further review or never see the light of day again.
Significant things not finalized:
- New Star changes largely were not finalized, which includes new measures, some Health Equity Index-related clarifications, and removal of guardrails.
- The administration also did not finalize other health equity-related reforms.
- It did not finalize Biden’s proposal to expand GLP-1 weight-loss drugs to those with just obesity but no other underlying disease states (e.g., diabetes). While many could have benefited, it was clear that MA and especially standalone Part D (PDP) plans would have had huge financial outlays here if this were to have been finalized. It would have led to benefit cutbacks in other areas. We need to get drug prices down!
- No medical loss ratio (MLR) changes. Some good ideas in general, but they need to be better thought out.
- No major marketing reforms. This is concerning given what is happening on the enrollment front.
CMS did finalize several things and this is by no means a full list:
- Requiring claims payment for inpatient claims previously approved by prior authorization
- Appeals reforms
- Some supplemental benefit reform related to chronically ill (SSBCI) benefits, but not all proposals in this area
- Risk adjustment technical adjustments
- Some dual eligible experience and integration proposals
- Codifying various aspects of changes in Part D from the Inflation Reduction Act (IRA)
- Some Medicare Prescription Payment Plan codification — not all proposals were finalized
- Prescription Drug Event (PDE) claims submission timeframes
- Other Part D technical issues
The Final Notice for rates and other Star measures should be out Monday as well.
CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/contract-year-2026-policy-and-technical-changes-medicare-advantage-program-medicare-prescription-final
Additional articles: https://www.fiercehealthcare.com/payers/medicare-advantage-final-rule-excludes-anti-obesity-drug-coverage-under-medicare-medicaid and https://insidehealthpolicy.com/daily-news/trump-finalizes-prior-auth-hospital-stay-reqs-medicare-advantage-rule and https://insidehealthpolicy.com/daily-news/cms-declines-finalize-ma-ai-guardrails-expresses-interest-future-ai-regulation and https://thehill.com/homenews/5233357-medicare-medicaid-obesity-biden-trump/ and https://insidehealthpolicy.com/daily-news/cms-scraps-biden-plan-cover-anti-obesity-medications and https://www.modernhealthcare.com/policy/medicare-advantage-prior-authorization-ai
(Some articles may require a subscription.)
#medicareadvantage #partd #cms #regulations #star #quality #glp1s #priorauthorization
https://www.modernhealthcare.com/politics-policy/medicare-obesity-drug-coverage-trump
FTC Chair Reverses Recusal And PBM Suit Can Proceed
Federal Trade Commission (FTC) Chair Andrew Ferguson has reversed course on his decision to recuse himself from the agency’s legal battle with pharmacy benefit managers. This gives three commissioners to participate in the administrative suit against pharmacy benefits managers (PBMs) over insulin prices.
In truth, while I support the challenge on insulin prices, the suit should be in a federal court.
Additional article: https://www.fiercehealthcare.com/regulatory/ftc-pauses-lawsuit-against-pbms-over-insulin-pricing and https://www.healthcaredive.com/news/ftc-pbm-case-move-forward-ferguson/744454/
(Some articles may require a subscription.)
#ftc #pbms #drugpricing #antitrust
https://www.modernhealthcare.com/legal/ftc-andrew-ferguson-cvs-caremark-express-scripts-optumrx
HHS Will Rescind 20% Of Most Recent Layoffs
Secretary Robert F. Kennedy Jr. said the Department of Health and Human Services (HHS) would rescind an estimated 2,000, or 20%, of the recent job cuts at the department.
#hhs #layoffs #healthcare
Healthcare Very Concerned About Medical Device Tariffs
Healthcare industry groups and analysts are very worried about the impact of President Donald Trump’s tariffs. While drugs were exempted, supplies and medical devices will see very high tariffs. America is very dependent on imports for such supplies and devices, especially from China.
#tariffs #healthcare #spending
https://www.healthcaredive.com/news/tariffs-aha-med-tech-brace-for-impact/744496
Gallup Says Those Who Cannot Afford Necessary Healthcare Reaches 4-Year High
A new Gallup poll says the number of Americans who could not afford to access necessary healthcare reached a four-year high last year. Eleven percent of people surveyed — roughly 29 million people — said they were unable to afford certain care in the past three months. More important, over one-third of respondents said that if they needed quality medical treatment today they would not be able to afford it.
These 29 million are part of the 85 million in the U.S. who are either uninsured or underinsured.
#uninsured #underinsured #healthcare #costs
https://www.healthcaredive.com/news/healthcare-increasingly-unaffordable-gallup/744324
— Marc S. Ryan
